HospitalInspections.org

Based on observation and staff interview the facility failed to provide confidentiality of clinical records to those patients receiving blood pressure medications and blood pressure monitoring. The facility failed to provide nursing care and service that follow the Professional Standards of Practice.

The findings include:

1. During a medication administration observation conducted on the 200 wing at 9:40 a.m. on 2/14/12 a Technician (Tech) was observed taking a blood pressure on Patient
#4. The Tech told the patient his blood pressure was 102/60 and handed him a small piece of white paper, approximately 3 inches square. Patient #4 brought this piece of paper to the nurse' station and handed it to the nurse. The nurse took the square of paper and placed it on top of her medication cart. Prior to giving Patient #4 his scheduled medication, the nurse asked the Tech, who was standing at the nurse's station, to give her the vital signs sheet. The Tech stated "I will show it to you later" and walked away from the nurse's station. The nurse gave the patient his medication at 9:50 a.m. Upon observation at this time, the square of white paper was noted to state "2/14/12, 9:45 a.m., 102/60." Patient #4's name was also indicated on this square of paper.

Upon interview on 2/14/12 at 10:45 a.m. with the Director of Nursing, Risk Manager and Nursing Supervisor, it was stated that using a square of white paper was not the procedure to be used when recording a patient's blood pressure. At 11:15 a.m. the Director Nursing and Risk Manager acknowledged the proper procedure for recording blood pressures was not being followed and represented a breach of patient confidentiality. They also stated the tech taking the blood pressure did not receive training relating to the recording of blood pressures per the facility plan of correction and quality assurance/performance improvement plan.
Review of the Medication Administration Record, on 2/14/12 at 11:30 a.m., revealed a blood pressure was recorded for Patient #4, as "0950 (9:50 a.m.), 102/60" with the nurse initials indicating that Suboxone, 2 mg/0.5 mg, 2 sublingual films were administered at 10 a.m. on 2/14/12.

2. During a medication administration observation conducted on the 100 wing at 10:00 a.m. on 02/14/12 Patient #10 presented to the medication window with a square piece of paper approximately 3 inches by 3 inches. The paper had a blood pressure reading documented on the paper. The paper included the patient name. The nurse asked the technician for the BP sheet. The technician stated "That will really slow us down, we have patients waiting." An observation through the medication room window revealed two other patients were standing near Patient #10. The other patients were standing on each side of Patient #10 and the piece of paper was face up with the blood pressure reading visible to the other patients. The tech reluctantly brought the VS sheet a few minutes later.
At 11:15 a.m. the Risk Manager (RM) explained the technicians should know better. The Director of Nursing (DON) stated "this is unacceptable." The DON continued to explain the clinical staff were provided inservices regarding the use of the new Vital Sign Information Sheet.

At 2:15 p.m. on 2/14/12 the Nursing Supervisor stated that an inservice had been given to all nurses and technicians on duty at this time, regarding the use of the "Nurse - Tech Vital Sign Information Sheet."